Checklists are written in blood. Treat them with respect accordingly...
15 May 1979
Douglas C-54S Skymaster, BuNo 56534, N44905
Mesa-Falcon Field (KFFZ), Mesa, Arizona
2 Serious (crew); 1 Minor (ground)
In the next three editions of MikeD's Accident Synopsis series, I again detail aviation accidents and incidents that I remember from my time growing up in Arizona, and while I had an interest in them when they were occurring and on the news, I never really looked into them in detail until my later teenage years. One of the interesting things I got to do growing up was spend alot of time around the various local airports in the metro Phoenix valley, including the surrounding cities. One of these fields, Mesa-Falcon, is one of the last of the airports in the valley with old classic aircraft still on the field, albeit relegated to the corners of the field or behind fenced compounds where they can't be seen. Most of the other valley airports have long ago gotten rid of the older aircraft on the field that are now considered eyesores, and Mesa-Falcon is no different in that regard, the only difference being Falcon hasn't gotten rid of theirs yet. At Falcon Field, there was once a company that specialized in aerial firefighting known as Globe Air; their fleet of Grumman TBM Avengers, their 6 Boeing B-17s, and their Douglas C-54 (military version of the DC-4) and Lockheed 1049 Constellations being major standouts on the airport up until the company went out of business in 1985. They worked in concert with other aerial firefighting and spraying companies such as Biegert Aviation and T&G Aviation, both located at Chandler-Memorial Field (34AZ) on the southwest side of the city of Chandler. Although out of business for the past 26 years, in 1979 business was booming, as Globe Air was a primary operator from Falcon Field, which at the time was located in almost the middle of nowhere amongst cotton fields and orange groves in the extreme north side of the city of Mesa. As the summer fire season of 1979 was beginning, many firebomber operators were getting their aircraft ready for immediate dispatch in anticipation of a busy wildfire season. Such was the case at the Globe Air facility on the late morning of 15 May 1979.
On that late Tuesday morning, the weather at KFFZ was 85 degrees with clear skies and light winds out of the southwest. A ground crew had completed some maintenance work on a 1944 Douglas C-54S owned by Biegert Aviation, but being operated by Globe Air for the upcoming fire season. N44905 was one of 13 C-54 aircraft based out of Chandler-Memorial field and owned by Biegert. All 13 had been prior US Army Air Force planes that were transferred to the US Navy and US Marine Corps, and had been eventually retired by 1971 to the-then Military Aircraft Storage and Disposition Center (MASDC) located at Davis-Monthan AFB (KDMA) in Tucson, Arizona. In 1975, the aircraft had been purchased at auction from KDMA and moved to 34AZ for conversion to their new lives as forest firefighting aircraft. N44905 was preparing for a test flight consisting of a short hop from KFFZ to Chandler-Stellar Airpark (P19) approximately 15nm to the southwest, with airwork inbetween. The flightcrew for the day's flight consisted of a 35 year old ATP-licensed Captain and a 21 year old Commercial-licensed Co-Pilot, both type rated in the C-54/DC-4 and with a combined 12,000+ hours and 4400 in-type between the two.
Following preflight, the flightcrew boarded the aircraft and began the pre-start checklists. Engine start of all 4 engines was uneventful as was the run-up. While today KFFZ is a towered field with parallel runways, in 1979 the airport had a single runway and no tower. What is now runway 4R/22L and 5100' in length, was then the single-runway 4-22, and 4300' in length. With prevailing winds out of the southwest at 10 knots, the crew of 44905 elected to taxi to RW 22. 44905 was loaded with about 75% fuel and empty of any cargo or firefighting slurry load. The TOLD data didn't reveal any problems getting airborne with a short takeoff run, and at approximately 1455L, 44905 radioed on the CTAF that they'd be departing RW 22 straight-out to the southwest. With the Captain handling the takeoff, the crew lined-up the aircraft, set takeoff power and released the brakes. Aircraft acceleration and check speed were normal, V1 and Vr were quickly attained, but as the Captain attempted to move the control column in order to rotate to takeoff attitude, the column wouldn't move. The Captain attempted a few more times to move the control column in quick succession, but with no success. With the end of the runway rapidly approaching, the crew finally decided to abort the takeoff. But with little runway remaining, by the time the throttles were closed and the mixtures cutoff, the aircraft was departing the end RW 22. While still moving at a fairly high rate of speed, 44905 overran the end of the 4300' runway, impacted a low dirt embankent near the airport perimeter fence, went through the fence and proceeded to cross Greenfield Road. At this exact moment, a pickup truck was southbound on Greenfield Road and 44905s number 3 engine and propeller stuck the truck, chopping it up, although completely missing the 20 year old driver, who only suffered minor injuries. 44905 continued across Greenfield Road, and into the adjacent orange grove located across the street on the northwest corner of Greenfield and McKellips Roads. The C-54 plowed approximately 200' into the grove, shedding both wings and all four engines once inside, and immediately erupting in a large post-crash fire.
With the cockpit being crushed by impact with the orange trees, both the crew ended up severely dazed; the Captain suffering a broken leg, but able to successfully free himself from the left cockpit window. The co-pilot also ended up dazed, suffering two broken legs and was trapped between his seat and the collapsed instrument panel and control column, with flames rapidly propogating to the cockpit area. At the time, KFFZ had only a small Index-Limited Crash-Fire-Rescue (CFR) truck, but by sheer luck this day, the small 3-man CFR/ARFF crew happened to be doing response training and doing the daily exercising of their truck in a field area not more than 100 yards from the accident scene, and were able to quickly respond, arriving on-scene in less than a minute. The CFR/ARFF crew were not able to completely extinguish the large fuel-fed fire, but were able to keep the fire away from the cockpit using both the water/foam from their small truck's onboard tank, as well as fire extinguishers, and begin extrication operations until larger engine companies could arrive and assist. With their arrival, the fire was completely extinguished and the trapped co-pilot was finally extricated from the crushed cockpit 40 minutes after the accident. Post-crash investigation of the remaining wreckage revealed that the elevator gust locks on 44905 were still engaged.
Probable Cause:
*Inadequate Preflight Planning and/or Preparation- Pilot in Command
*Failure to Abort Takeoff- Pilot in Command
Secondary Factors:
*Miscellaneous Acts, Conditions- Checklists- Failed to Use- Crew
*Miscellaneous Acts, Conditions- Gust Locks- Engaged
Tertiary Factors:
None
MikeD says:
This accident is another reminder that no matter how routine an operation may seem, and no matter how experienced a flightcrew may be; old Mr Murphy is always waiting around the corner for any opportunity to make what can go wrong, go wrong. He's ready to throw a monkey wrench into the most efficient plans and the best of intentions. The crew of 44905 had a very experienced Captain and a lesser experienced co-pilot, but between the two of them they were well current and qualified to be doing what they were doing that day. The monkey wrench that caught this crew off-guard, and the discussion I'll undertake with this accident, will center around the Primary and Secondary causal factors of this accident, specifically:
1. Adequate preflight and checklist usage
2. The DC-4/C-54 gust lock system
3. Timely abort decision making
Adequate Preflight and Checklist Usage: A number of mistakes were made by the crew of 44905 in both preflight as well as checklist usage. Although the ground crew accomplished a good portion of the preparation of 44905 following the maintenance that was just completed, the flight crew didn't adequately preflight the C-54. On the C-54/DC-4, it's not normally possible to physically manipulate the elevators, ailerons or rudder due to their respective heights above the ground. However a visual indication of the gust lock being unlocked would be the elevators trailing downward. Even if the gust lock was engaged during preflight, it should've been caught at any time between engine start and commencing the takeoff roll during the customary flight controls "free and correct" check; a check both intuitive as well as called for by the C-54 checklist being used at the time by the crew, coming after the fuel selectors positioning step and before the flaps and elevator trim setting steps. The fact that the engaged gust lock was missed both in preflight as well as all the way through takeoff reveals either a large case of complacency or distraction by the crew, or a very low level of situational awareness (SA). What is perplexing is that witness accounts don't indicate that the flightcrew was rushing or hurried in any way, which would normally discount the distraction factor. The high overall experience level of the crew could have a directly proportional relation to the complacency factor, but should definitely have a directly proportional relation to the SA factor. What creates the perplexing factor to this accident is that none of the "usual suspects" of aforementioned factors fit in rationally with the evidence at hand of either the situation or the crew makeup and operating dynamic. There's no rational reason why the crew should've been caught by inadequate preflight or failure to use the checklist. Without a Cockpit Voice Recorder (CVR) onboard, and no legal requirement for one, it will never be known what exactly transpired in the cockpit of 44905 from the time the cabin door closed, to the time the airplane came to rest in the orange grove.
The DC-4/C-54 Gust Lock System: Another unexplainable primary causal factor in this accident was how the C-54s engaged cockpit gust lock was missed in the first place, simply due to its location in the cockpit and by some of the functionality of the system. In the DC-4/C-54 aircraft, the flight control gust lock in the cockpit is cable operated and located on the cockpit floor just aft of both the Captain's seat and the left-aft corner of the center console (where the mixture knobs for all four engines are located), and inbetween the two. It's located directly cross-cockpit from the landing gear emergency hand pump, located similarly on the cockpit floor between the co-pilots seat and the right-aft corner of the center console (where the supercharger knobs and cowl flap knobs for all four engines are located). In this location, the gust lock actuator is a large red control handle made of magnesium that is engaged when in the "up" positon, and disengaged when stowed against the cockpit floor in the "down" position. In the "up" (locked) position, the handle is held in-place with a stainless steel pin. This pin is attached to a wide red-in-color lanyard that is attached to a retractable reel located in the cockpit ceiling adjacent to the left-forward portion of the overhead console, overhead the Captain's right armrest. When the gust lock is engaged, this retractable lanyard with the pin coming down from the ceiling effectively blocks access to the Captain's seat and is extremely difficult to miss (see picture at bottom of this report). Without it or the pin installed, the gust lock handle will not stay up in the engaged position, and will recoil back to the down/disengaged position. In the DC-4/C-54 series aircraft, it's been known for flight and maintenance crews to often unreel the excess red-lanyard tape from the ceiling, and tuck the assembly behind the Captain's seat in order to facilitate getting into or out of the Captain's seat when performing maintenance, etc. Still, it's nearly impossible to get into the Captain's seat without tripping on, or noticeably having to step over the engaged (upright) gust lock handle.
There has been a common problem with the DC-4/C-54 gust lock system in aircraft where the cabling has become loose or otherwise out of rig and the spring in the gust lock handle as become worn. This allows the gust lock handle to unseat from its stowed position and possibly allow the gust locks to engage during taxi or inflight. The problem has been known since 1947 following the takeoff accident of United Airlines 521, a DC-4 on takeoff from KLGA to KCLE. The dynamics of that accident in terms of what occurred on takeoff, are nearly similar to the accident of 44905. In that accident, it was found that the gust locks had been altered by the airline, in a way that allowed the lock to remain engaged even after removal of the pin and tape. The then-Civil Aeronautics Administration (CAA) issued Airworthiness Directive (AD) 47-42-01 requiring a latch safety mechanism be installed to insure the gust lock handle remain seated in the unlocked position when placed there.
Timely Abort Decision Making: One of the primary causal factors to N44905 ending up where it did off the end of RW22 and into the orange grove, destroyed; versus ending up stopped at the end of the runway, was the flightcrew's failure to initiate a timely abort on takeoff. Even putting aside the previous discussion of how the engaged gust lock was missed in the first place and the lack of any check of the flight controls being free and correct, had an efficient takeoff abort been initiated in a more timely manner at the first sign of something being awry with the flight controls, it's entirely probable that the aircraft would've been successfully stopped on the 4300' runway at best, and into the overrun at worst. The fact that the crew attempted to diagnose or figure out a flight control problem while accelerating down an already-tight runway, severely lessened their chances for a successful outcome other than what they had. With any flight control malfunction, the chances of taking a sick aircraft airborne successfully, versus excuting a timely and efficient abort successfully, are fully dependant on a number of factors and variables. But generally speaking, a flight control malfunction such as the one the crew of 44905 experienced, should've been a guaranteed abort-now decision, as any kind of takeoff would've been catastrophic, had it occurred. Unfortunately, the combination of a short runway, a late abort decision, a dirt berm and perimeter fence, a pickup truck, and an orange grove, all combined to seal the fate of the crew to a catastrophic ending anyway. The crew of 44905 had boxed themselves into a square corner with no real good escape, not long after brake release, due to errors of both commission as well as omission.
MikeDs Final Thoughts: This accident is one of those ones where the crew, for reasons entirely unexplainable as detailed above, did key things wrong from the very beginning of the mission. Each error kept adding up, but these errors weren't commensurate with the mitigating factors that were supposed to be present. Without being rushed, distraction shouldn't have been a factor. With a great deal of experience present, situational awareness shouldn't have been a problem. Even complacency should've been able to be mitigated if only for the design of the gust lock handle being difficult to miss when engaged. While the what and a good portion of the how of this accident is known, most all of the why is still a mystery. That Mr Murphy could get his fingers so deep into the catastrophe of what the last takeoff of N44905 became, is very difficult to conceive; but the square corner that the flightcrew allowed Murphy to place them in put them directly on the Long Roll to a Short Demise, with no other outcome but what occurred.
On a personal note, the FAA examiner who gave me my initial CFI ride in 1992, was the FAA investigator along with the NTSB on this accident which he mentioned in our debrief. Long since deceased, I kick myself for not picking his brain back then for the priceless firsthand information that he had from this one.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
Photo: Douglas C-54D Skymaster cockpit showing gust lock webbing attachment from ceiling, attached to the engaged gust lock handle on floor. (Photo credit: J. Snyder)
15 May 1979
Douglas C-54S Skymaster, BuNo 56534, N44905
Mesa-Falcon Field (KFFZ), Mesa, Arizona
2 Serious (crew); 1 Minor (ground)
In the next three editions of MikeD's Accident Synopsis series, I again detail aviation accidents and incidents that I remember from my time growing up in Arizona, and while I had an interest in them when they were occurring and on the news, I never really looked into them in detail until my later teenage years. One of the interesting things I got to do growing up was spend alot of time around the various local airports in the metro Phoenix valley, including the surrounding cities. One of these fields, Mesa-Falcon, is one of the last of the airports in the valley with old classic aircraft still on the field, albeit relegated to the corners of the field or behind fenced compounds where they can't be seen. Most of the other valley airports have long ago gotten rid of the older aircraft on the field that are now considered eyesores, and Mesa-Falcon is no different in that regard, the only difference being Falcon hasn't gotten rid of theirs yet. At Falcon Field, there was once a company that specialized in aerial firefighting known as Globe Air; their fleet of Grumman TBM Avengers, their 6 Boeing B-17s, and their Douglas C-54 (military version of the DC-4) and Lockheed 1049 Constellations being major standouts on the airport up until the company went out of business in 1985. They worked in concert with other aerial firefighting and spraying companies such as Biegert Aviation and T&G Aviation, both located at Chandler-Memorial Field (34AZ) on the southwest side of the city of Chandler. Although out of business for the past 26 years, in 1979 business was booming, as Globe Air was a primary operator from Falcon Field, which at the time was located in almost the middle of nowhere amongst cotton fields and orange groves in the extreme north side of the city of Mesa. As the summer fire season of 1979 was beginning, many firebomber operators were getting their aircraft ready for immediate dispatch in anticipation of a busy wildfire season. Such was the case at the Globe Air facility on the late morning of 15 May 1979.
On that late Tuesday morning, the weather at KFFZ was 85 degrees with clear skies and light winds out of the southwest. A ground crew had completed some maintenance work on a 1944 Douglas C-54S owned by Biegert Aviation, but being operated by Globe Air for the upcoming fire season. N44905 was one of 13 C-54 aircraft based out of Chandler-Memorial field and owned by Biegert. All 13 had been prior US Army Air Force planes that were transferred to the US Navy and US Marine Corps, and had been eventually retired by 1971 to the-then Military Aircraft Storage and Disposition Center (MASDC) located at Davis-Monthan AFB (KDMA) in Tucson, Arizona. In 1975, the aircraft had been purchased at auction from KDMA and moved to 34AZ for conversion to their new lives as forest firefighting aircraft. N44905 was preparing for a test flight consisting of a short hop from KFFZ to Chandler-Stellar Airpark (P19) approximately 15nm to the southwest, with airwork inbetween. The flightcrew for the day's flight consisted of a 35 year old ATP-licensed Captain and a 21 year old Commercial-licensed Co-Pilot, both type rated in the C-54/DC-4 and with a combined 12,000+ hours and 4400 in-type between the two.
Following preflight, the flightcrew boarded the aircraft and began the pre-start checklists. Engine start of all 4 engines was uneventful as was the run-up. While today KFFZ is a towered field with parallel runways, in 1979 the airport had a single runway and no tower. What is now runway 4R/22L and 5100' in length, was then the single-runway 4-22, and 4300' in length. With prevailing winds out of the southwest at 10 knots, the crew of 44905 elected to taxi to RW 22. 44905 was loaded with about 75% fuel and empty of any cargo or firefighting slurry load. The TOLD data didn't reveal any problems getting airborne with a short takeoff run, and at approximately 1455L, 44905 radioed on the CTAF that they'd be departing RW 22 straight-out to the southwest. With the Captain handling the takeoff, the crew lined-up the aircraft, set takeoff power and released the brakes. Aircraft acceleration and check speed were normal, V1 and Vr were quickly attained, but as the Captain attempted to move the control column in order to rotate to takeoff attitude, the column wouldn't move. The Captain attempted a few more times to move the control column in quick succession, but with no success. With the end of the runway rapidly approaching, the crew finally decided to abort the takeoff. But with little runway remaining, by the time the throttles were closed and the mixtures cutoff, the aircraft was departing the end RW 22. While still moving at a fairly high rate of speed, 44905 overran the end of the 4300' runway, impacted a low dirt embankent near the airport perimeter fence, went through the fence and proceeded to cross Greenfield Road. At this exact moment, a pickup truck was southbound on Greenfield Road and 44905s number 3 engine and propeller stuck the truck, chopping it up, although completely missing the 20 year old driver, who only suffered minor injuries. 44905 continued across Greenfield Road, and into the adjacent orange grove located across the street on the northwest corner of Greenfield and McKellips Roads. The C-54 plowed approximately 200' into the grove, shedding both wings and all four engines once inside, and immediately erupting in a large post-crash fire.
With the cockpit being crushed by impact with the orange trees, both the crew ended up severely dazed; the Captain suffering a broken leg, but able to successfully free himself from the left cockpit window. The co-pilot also ended up dazed, suffering two broken legs and was trapped between his seat and the collapsed instrument panel and control column, with flames rapidly propogating to the cockpit area. At the time, KFFZ had only a small Index-Limited Crash-Fire-Rescue (CFR) truck, but by sheer luck this day, the small 3-man CFR/ARFF crew happened to be doing response training and doing the daily exercising of their truck in a field area not more than 100 yards from the accident scene, and were able to quickly respond, arriving on-scene in less than a minute. The CFR/ARFF crew were not able to completely extinguish the large fuel-fed fire, but were able to keep the fire away from the cockpit using both the water/foam from their small truck's onboard tank, as well as fire extinguishers, and begin extrication operations until larger engine companies could arrive and assist. With their arrival, the fire was completely extinguished and the trapped co-pilot was finally extricated from the crushed cockpit 40 minutes after the accident. Post-crash investigation of the remaining wreckage revealed that the elevator gust locks on 44905 were still engaged.
Probable Cause:
*Inadequate Preflight Planning and/or Preparation- Pilot in Command
*Failure to Abort Takeoff- Pilot in Command
Secondary Factors:
*Miscellaneous Acts, Conditions- Checklists- Failed to Use- Crew
*Miscellaneous Acts, Conditions- Gust Locks- Engaged
Tertiary Factors:
None
MikeD says:
This accident is another reminder that no matter how routine an operation may seem, and no matter how experienced a flightcrew may be; old Mr Murphy is always waiting around the corner for any opportunity to make what can go wrong, go wrong. He's ready to throw a monkey wrench into the most efficient plans and the best of intentions. The crew of 44905 had a very experienced Captain and a lesser experienced co-pilot, but between the two of them they were well current and qualified to be doing what they were doing that day. The monkey wrench that caught this crew off-guard, and the discussion I'll undertake with this accident, will center around the Primary and Secondary causal factors of this accident, specifically:
1. Adequate preflight and checklist usage
2. The DC-4/C-54 gust lock system
3. Timely abort decision making
Adequate Preflight and Checklist Usage: A number of mistakes were made by the crew of 44905 in both preflight as well as checklist usage. Although the ground crew accomplished a good portion of the preparation of 44905 following the maintenance that was just completed, the flight crew didn't adequately preflight the C-54. On the C-54/DC-4, it's not normally possible to physically manipulate the elevators, ailerons or rudder due to their respective heights above the ground. However a visual indication of the gust lock being unlocked would be the elevators trailing downward. Even if the gust lock was engaged during preflight, it should've been caught at any time between engine start and commencing the takeoff roll during the customary flight controls "free and correct" check; a check both intuitive as well as called for by the C-54 checklist being used at the time by the crew, coming after the fuel selectors positioning step and before the flaps and elevator trim setting steps. The fact that the engaged gust lock was missed both in preflight as well as all the way through takeoff reveals either a large case of complacency or distraction by the crew, or a very low level of situational awareness (SA). What is perplexing is that witness accounts don't indicate that the flightcrew was rushing or hurried in any way, which would normally discount the distraction factor. The high overall experience level of the crew could have a directly proportional relation to the complacency factor, but should definitely have a directly proportional relation to the SA factor. What creates the perplexing factor to this accident is that none of the "usual suspects" of aforementioned factors fit in rationally with the evidence at hand of either the situation or the crew makeup and operating dynamic. There's no rational reason why the crew should've been caught by inadequate preflight or failure to use the checklist. Without a Cockpit Voice Recorder (CVR) onboard, and no legal requirement for one, it will never be known what exactly transpired in the cockpit of 44905 from the time the cabin door closed, to the time the airplane came to rest in the orange grove.
The DC-4/C-54 Gust Lock System: Another unexplainable primary causal factor in this accident was how the C-54s engaged cockpit gust lock was missed in the first place, simply due to its location in the cockpit and by some of the functionality of the system. In the DC-4/C-54 aircraft, the flight control gust lock in the cockpit is cable operated and located on the cockpit floor just aft of both the Captain's seat and the left-aft corner of the center console (where the mixture knobs for all four engines are located), and inbetween the two. It's located directly cross-cockpit from the landing gear emergency hand pump, located similarly on the cockpit floor between the co-pilots seat and the right-aft corner of the center console (where the supercharger knobs and cowl flap knobs for all four engines are located). In this location, the gust lock actuator is a large red control handle made of magnesium that is engaged when in the "up" positon, and disengaged when stowed against the cockpit floor in the "down" position. In the "up" (locked) position, the handle is held in-place with a stainless steel pin. This pin is attached to a wide red-in-color lanyard that is attached to a retractable reel located in the cockpit ceiling adjacent to the left-forward portion of the overhead console, overhead the Captain's right armrest. When the gust lock is engaged, this retractable lanyard with the pin coming down from the ceiling effectively blocks access to the Captain's seat and is extremely difficult to miss (see picture at bottom of this report). Without it or the pin installed, the gust lock handle will not stay up in the engaged position, and will recoil back to the down/disengaged position. In the DC-4/C-54 series aircraft, it's been known for flight and maintenance crews to often unreel the excess red-lanyard tape from the ceiling, and tuck the assembly behind the Captain's seat in order to facilitate getting into or out of the Captain's seat when performing maintenance, etc. Still, it's nearly impossible to get into the Captain's seat without tripping on, or noticeably having to step over the engaged (upright) gust lock handle.
There has been a common problem with the DC-4/C-54 gust lock system in aircraft where the cabling has become loose or otherwise out of rig and the spring in the gust lock handle as become worn. This allows the gust lock handle to unseat from its stowed position and possibly allow the gust locks to engage during taxi or inflight. The problem has been known since 1947 following the takeoff accident of United Airlines 521, a DC-4 on takeoff from KLGA to KCLE. The dynamics of that accident in terms of what occurred on takeoff, are nearly similar to the accident of 44905. In that accident, it was found that the gust locks had been altered by the airline, in a way that allowed the lock to remain engaged even after removal of the pin and tape. The then-Civil Aeronautics Administration (CAA) issued Airworthiness Directive (AD) 47-42-01 requiring a latch safety mechanism be installed to insure the gust lock handle remain seated in the unlocked position when placed there.
Timely Abort Decision Making: One of the primary causal factors to N44905 ending up where it did off the end of RW22 and into the orange grove, destroyed; versus ending up stopped at the end of the runway, was the flightcrew's failure to initiate a timely abort on takeoff. Even putting aside the previous discussion of how the engaged gust lock was missed in the first place and the lack of any check of the flight controls being free and correct, had an efficient takeoff abort been initiated in a more timely manner at the first sign of something being awry with the flight controls, it's entirely probable that the aircraft would've been successfully stopped on the 4300' runway at best, and into the overrun at worst. The fact that the crew attempted to diagnose or figure out a flight control problem while accelerating down an already-tight runway, severely lessened their chances for a successful outcome other than what they had. With any flight control malfunction, the chances of taking a sick aircraft airborne successfully, versus excuting a timely and efficient abort successfully, are fully dependant on a number of factors and variables. But generally speaking, a flight control malfunction such as the one the crew of 44905 experienced, should've been a guaranteed abort-now decision, as any kind of takeoff would've been catastrophic, had it occurred. Unfortunately, the combination of a short runway, a late abort decision, a dirt berm and perimeter fence, a pickup truck, and an orange grove, all combined to seal the fate of the crew to a catastrophic ending anyway. The crew of 44905 had boxed themselves into a square corner with no real good escape, not long after brake release, due to errors of both commission as well as omission.
MikeDs Final Thoughts: This accident is one of those ones where the crew, for reasons entirely unexplainable as detailed above, did key things wrong from the very beginning of the mission. Each error kept adding up, but these errors weren't commensurate with the mitigating factors that were supposed to be present. Without being rushed, distraction shouldn't have been a factor. With a great deal of experience present, situational awareness shouldn't have been a problem. Even complacency should've been able to be mitigated if only for the design of the gust lock handle being difficult to miss when engaged. While the what and a good portion of the how of this accident is known, most all of the why is still a mystery. That Mr Murphy could get his fingers so deep into the catastrophe of what the last takeoff of N44905 became, is very difficult to conceive; but the square corner that the flightcrew allowed Murphy to place them in put them directly on the Long Roll to a Short Demise, with no other outcome but what occurred.
On a personal note, the FAA examiner who gave me my initial CFI ride in 1992, was the FAA investigator along with the NTSB on this accident which he mentioned in our debrief. Long since deceased, I kick myself for not picking his brain back then for the priceless firsthand information that he had from this one.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
Photo: Douglas C-54D Skymaster cockpit showing gust lock webbing attachment from ceiling, attached to the engaged gust lock handle on floor. (Photo credit: J. Snyder)
Last edited:
